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Spinal anesthesia in obstetrics
SPINAL ANESTHESIA IN OBSTETRICS* S.A. COSGROVE, M.D., F.A.C.S.
JERSEY CITY
S
PINAL anesthesia in a11 fieIds of surgery has severa definite advantages, among which are: CompIete anaIgesia; entire reIaxation of skeIeta1 muscuIature; preservation of tone of viscera1 muscuIature; absence of respiratory, cardiac, hepatic and renaI irritation; minima1 penetration of shock impuIses to cerebra1 cortex; Iessened bIeeding during operation; reIative freedom from postoperative nausea and iIeus; immediate postoperative ability to ingest nutriment. In obstetric surgery a11 of these advantages are equaIIy important as in other branches; some of them more important. The preservatron of uterme tone Iessens the tendency to hemorrhage during and after the third stage. The reIaxation of skeIeta1 muscIes reduces the risk of Iaceration of soft parts. The absence of renaI and hepatic irritation is especiaIIy significant in pregnancy, which state so frequentIy makes inordinate demands on the functiona capacity of Iiver and kidneys. The preservation of the patient’s consciousness permits a degree of voIuntary co-operation by the patient, which is required in few circumstances pertaining to other types of surgery, but is very heIpfu1 in obstetrics. Of especia1 moment is the fact that spinal anesthesia has in no sense or degree any deIeterious effect on the fetus. There has been no case in our experience in which asphyxia or death of the fetus was even remoteIy attributabIe to this anesthesia. The advantages pointed out as of genera1 appIication to a11 obstetrica patients are even more important in the deIivery of those exhibiting hepatic or renaI toxemias. In spite of the great recent refinement in the choice and administration of inhaIation narcotics, the researches of Stander and *Submitted
others confirm the fact of the potential damage to Iiver and kidneys inherent in a11 such agents. No such potentiaIity resides in spina anesthesia and it is in these cIasses of cases especiaIIy that it becomes preeminentIy the anesthesia of choice. It is aIso most heIpfu1 in cases in which cardiac insuffIciency compIicates pregnancy or Iabor; here the eIimination of a11 shock and the reIief to the Iaboring heart by the Iowering of bIood pressure tend greatIy to minimize the extreme urgency of many of these cases. In acute or chronic disease of any part of the respiratory tract spinal anesthesia absoIuteIy eIiminates IocaI irritation. As obstetrica surgery is never eIective in point of time with reference to the course of such diseases, the avaiIabiIity of this method becomes an important factor in handIing these cases with a minimum of risk. Our experience has not Ied us to recognize any serious disadvantages. BIood pressure faI1, formerIy much dreaded in connection with its use, has ceased to occasion anxiety. This depends partly on the use of ephedrine to combat hypotension, but more importantIy on the fact that the Iimited area of anesthesia necessary in any type of obstetrica operative procedure permits the use of the anesthetic agent in doses so smaI1 and at so Iow a IeveI, that the danger from Iowered bIood pressure is aImost negIigibIe apart from the use of any medicina1 agent to offset it. The short duration of anesthesia, averaging about three quarters of an hour, is rareIy of moment in obstetrica procedures, most of which can easiIy be compIeted within this time. Vomiting occurs occasionaIIy, but is rareIy severe or protracted.
for pubEcation,
602
November
2, rgz8.
NEW SERIES VOL. V, No. 6
Cosgrove-SpinaI
In onIy I of over 400 cases was this a distressing symptom. occur, Postoperative headache does being referred principaIIy to the vertex and the suboccipita1 region; it is occasionaIIy severe and is rareIy protracted for severa days; we believe it can be aImost whoIIy prevented by care in technique and the proper seIection of needIes. Subjective apprehension is occasionaIIy encountered, especiaIIy when the patient has anticipated reIief by inhaIation narcosis; such apprehension is readiIy amenabIe to suggestion, however, and disappears when the patient experiences the prompt and compIete disappearance of her pain. Some patients exhibit menta1 disturbance because of the paresthesia of the Iower extremities which is common, but these may be easiIy reassured. In practicaIIy a11 cases the fina psychic impression is favorabIe, often extravagantIy so, especiaIIy in patients who have had previous experiences with other methods of anesthesia. In onIy I of our cases was there any persistent unpIeasant seque1; this was a miId paresthesia of one thigh, Iasting four weeks. There is, of course, a certain dexterity to be attained and certain detaiIs of technique to be observed, faiIure in which wiI1 make for unsatisfactory resuIts. But inasmuch as this hoIds true in appIying any method of anesthesia it is of no especiaI force reIative to spina anesthesia. The method is practicabIe and desirabIe for routine use in a11 types of operative obstetrics. We used to beIieve that arteria1 hypotension was a contraindication, but have practicaIIy abandoned this criterion, even in severeIy shocked patients, for both our own carefu1 observations and those of others have shown that the bIood pressure faI1 is proportioned to the initia1 bIood pressure IeveI; that is, where the initiaI bIood pressure is high, the faII thereof foIIowing the spina injection is considerabIe, whereas, if the initia1 bIood pressure be very Iow, the further faII resuIting from the spina injection is negIigibIe. We aIso beIieve that spina anesthesia
Anesthesia
American Journd
of Surgery
603
has a restricted usefulness in the termination of the second stage of norma Iabor, a phase of the matter which is deaIt with in materia1 now in course of publication. Our method of administering spina anesthesia is a modification of that of Labat. We have found no advantage in the use of commerciaIIy prepared anesthetic soIutions. For a11procedures at the perinea1 IeveI, Iow forceps extraction, episiotomy, perineorraphy--go mg. of crystaIIized novocaine dissoIved in 2.5 cc. of spina fluid is injected into the fourth Iumbar interspace. For other intravagina1 operative manipuIation-diIatation or incision of the cervix, forceps appIications at the IeveI of the inIet, breech extractions, podaIic version, craniotomy and extraction, vagina1 hysterotomy--go mg. of novocaine in the third lumbar space is used. For obstetrica Iaparotomies we empIoy IOO mg. novocaine in the third Iumbar interspace. AI1 intraspina1 injections are preceded ten minutes by one 50 mg. ampuIe of ephedrine suIphate hypodermaticaIIy. A skin-whea1 is made with 0.5 per cent soIution of novocaine before introducing the spina needIe. The type of needIe used is important. It shouId be of No. 22 or No. 20 gauge and may be of any materia1 avaiIabIe. The conicaI-pointed needIe of Greene is theoreticaIIy advantageous, but if it impinges against bone in its introduction, the point may spIit, resuIting in a two-pronged point which cannot but Iacerate the dura UnnecessariIy. We have come to prefer a sharp short-beveIed needIe, such as those of Babcock or Pitkin. The injection is given the patient in the IateraI prone posture, with Iegs and thighs we11 ffexed and with the head bowed we11 forward. This is somewhat awkward, but can be accompIished by having an assistant steady and heIp the patient; on the whoIe, we think it is Iess distressing to a patient in the throes of Iabor than the stooped sitting posture. There is IittIe difference between the two as to the faciIity of introducing the needIe. The Iatter is inserted exactIy in the mid-
604
American
Journal
of Surgery
Cosgrove-SpinaI
Iine, midway between the contiguous dorsal spines at the IeveI seIected, exactIy perpendicuIar to both the sagitta1 and transverse body pIanes. If diffIcuIty is encountered by impingement against bone before the spina cana is entered, direction of the needIe sIightIy more cephaI-ward wiI1 usually overcome it. If it does not readiIy do so, it is usuaIIy best to withdraw and reinsert the needIe. UsuaIIy the sIight, but somewhat sharp eIastic resistance encountered in penetrating the dura is recognizabIe, and serves to orient the point of the needIe; if it does not, the needIe impinges against the centrum of the vertebra and shouId then be sIightIy withdrawn. Sharp
Anesthesia
DECEMBER,
1928
pain referred to either Ieg, or a flow of bIood from the needIe indicates that the point has been directed too much IateraIIy; it shouId be withdrawn and reinserted, sometimes best at the next higher IeveI. The end resuIts have been uniformIy satisfactory except as above noted. The anesthesia ensues very promptIy upon the injection, and passes off just as promptly. There is no post-anesthetic depression, distress, or disturbance of menta1 equilibrium. The method as appIied to obstetrics is again offered, not in any sense as original, but as one deserving, in the interest of much wider use than it has patients, hitherto enjoyed.
JERSEY CITY
S
PINAL anesthesia in a11 fieIds of surgery has severa definite advantages, among which are: CompIete anaIgesia; entire reIaxation of skeIeta1 muscuIature; preservation of tone of viscera1 muscuIature; absence of respiratory, cardiac, hepatic and renaI irritation; minima1 penetration of shock impuIses to cerebra1 cortex; Iessened bIeeding during operation; reIative freedom from postoperative nausea and iIeus; immediate postoperative ability to ingest nutriment. In obstetric surgery a11 of these advantages are equaIIy important as in other branches; some of them more important. The preservatron of uterme tone Iessens the tendency to hemorrhage during and after the third stage. The reIaxation of skeIeta1 muscIes reduces the risk of Iaceration of soft parts. The absence of renaI and hepatic irritation is especiaIIy significant in pregnancy, which state so frequentIy makes inordinate demands on the functiona capacity of Iiver and kidneys. The preservation of the patient’s consciousness permits a degree of voIuntary co-operation by the patient, which is required in few circumstances pertaining to other types of surgery, but is very heIpfu1 in obstetrics. Of especia1 moment is the fact that spinal anesthesia has in no sense or degree any deIeterious effect on the fetus. There has been no case in our experience in which asphyxia or death of the fetus was even remoteIy attributabIe to this anesthesia. The advantages pointed out as of genera1 appIication to a11 obstetrica patients are even more important in the deIivery of those exhibiting hepatic or renaI toxemias. In spite of the great recent refinement in the choice and administration of inhaIation narcotics, the researches of Stander and *Submitted
others confirm the fact of the potential damage to Iiver and kidneys inherent in a11 such agents. No such potentiaIity resides in spina anesthesia and it is in these cIasses of cases especiaIIy that it becomes preeminentIy the anesthesia of choice. It is aIso most heIpfu1 in cases in which cardiac insuffIciency compIicates pregnancy or Iabor; here the eIimination of a11 shock and the reIief to the Iaboring heart by the Iowering of bIood pressure tend greatIy to minimize the extreme urgency of many of these cases. In acute or chronic disease of any part of the respiratory tract spinal anesthesia absoIuteIy eIiminates IocaI irritation. As obstetrica surgery is never eIective in point of time with reference to the course of such diseases, the avaiIabiIity of this method becomes an important factor in handIing these cases with a minimum of risk. Our experience has not Ied us to recognize any serious disadvantages. BIood pressure faI1, formerIy much dreaded in connection with its use, has ceased to occasion anxiety. This depends partly on the use of ephedrine to combat hypotension, but more importantIy on the fact that the Iimited area of anesthesia necessary in any type of obstetrica operative procedure permits the use of the anesthetic agent in doses so smaI1 and at so Iow a IeveI, that the danger from Iowered bIood pressure is aImost negIigibIe apart from the use of any medicina1 agent to offset it. The short duration of anesthesia, averaging about three quarters of an hour, is rareIy of moment in obstetrica procedures, most of which can easiIy be compIeted within this time. Vomiting occurs occasionaIIy, but is rareIy severe or protracted.
for pubEcation,
602
November
2, rgz8.
NEW SERIES VOL. V, No. 6
Cosgrove-SpinaI
In onIy I of over 400 cases was this a distressing symptom. occur, Postoperative headache does being referred principaIIy to the vertex and the suboccipita1 region; it is occasionaIIy severe and is rareIy protracted for severa days; we believe it can be aImost whoIIy prevented by care in technique and the proper seIection of needIes. Subjective apprehension is occasionaIIy encountered, especiaIIy when the patient has anticipated reIief by inhaIation narcosis; such apprehension is readiIy amenabIe to suggestion, however, and disappears when the patient experiences the prompt and compIete disappearance of her pain. Some patients exhibit menta1 disturbance because of the paresthesia of the Iower extremities which is common, but these may be easiIy reassured. In practicaIIy a11 cases the fina psychic impression is favorabIe, often extravagantIy so, especiaIIy in patients who have had previous experiences with other methods of anesthesia. In onIy I of our cases was there any persistent unpIeasant seque1; this was a miId paresthesia of one thigh, Iasting four weeks. There is, of course, a certain dexterity to be attained and certain detaiIs of technique to be observed, faiIure in which wiI1 make for unsatisfactory resuIts. But inasmuch as this hoIds true in appIying any method of anesthesia it is of no especiaI force reIative to spina anesthesia. The method is practicabIe and desirabIe for routine use in a11 types of operative obstetrics. We used to beIieve that arteria1 hypotension was a contraindication, but have practicaIIy abandoned this criterion, even in severeIy shocked patients, for both our own carefu1 observations and those of others have shown that the bIood pressure faI1 is proportioned to the initia1 bIood pressure IeveI; that is, where the initiaI bIood pressure is high, the faII thereof foIIowing the spina injection is considerabIe, whereas, if the initia1 bIood pressure be very Iow, the further faII resuIting from the spina injection is negIigibIe. We aIso beIieve that spina anesthesia
Anesthesia
American Journd
of Surgery
603
has a restricted usefulness in the termination of the second stage of norma Iabor, a phase of the matter which is deaIt with in materia1 now in course of publication. Our method of administering spina anesthesia is a modification of that of Labat. We have found no advantage in the use of commerciaIIy prepared anesthetic soIutions. For a11procedures at the perinea1 IeveI, Iow forceps extraction, episiotomy, perineorraphy--go mg. of crystaIIized novocaine dissoIved in 2.5 cc. of spina fluid is injected into the fourth Iumbar interspace. For other intravagina1 operative manipuIation-diIatation or incision of the cervix, forceps appIications at the IeveI of the inIet, breech extractions, podaIic version, craniotomy and extraction, vagina1 hysterotomy--go mg. of novocaine in the third lumbar space is used. For obstetrica Iaparotomies we empIoy IOO mg. novocaine in the third Iumbar interspace. AI1 intraspina1 injections are preceded ten minutes by one 50 mg. ampuIe of ephedrine suIphate hypodermaticaIIy. A skin-whea1 is made with 0.5 per cent soIution of novocaine before introducing the spina needIe. The type of needIe used is important. It shouId be of No. 22 or No. 20 gauge and may be of any materia1 avaiIabIe. The conicaI-pointed needIe of Greene is theoreticaIIy advantageous, but if it impinges against bone in its introduction, the point may spIit, resuIting in a two-pronged point which cannot but Iacerate the dura UnnecessariIy. We have come to prefer a sharp short-beveIed needIe, such as those of Babcock or Pitkin. The injection is given the patient in the IateraI prone posture, with Iegs and thighs we11 ffexed and with the head bowed we11 forward. This is somewhat awkward, but can be accompIished by having an assistant steady and heIp the patient; on the whoIe, we think it is Iess distressing to a patient in the throes of Iabor than the stooped sitting posture. There is IittIe difference between the two as to the faciIity of introducing the needIe. The Iatter is inserted exactIy in the mid-
604
American
Journal
of Surgery
Cosgrove-SpinaI
Iine, midway between the contiguous dorsal spines at the IeveI seIected, exactIy perpendicuIar to both the sagitta1 and transverse body pIanes. If diffIcuIty is encountered by impingement against bone before the spina cana is entered, direction of the needIe sIightIy more cephaI-ward wiI1 usually overcome it. If it does not readiIy do so, it is usuaIIy best to withdraw and reinsert the needIe. UsuaIIy the sIight, but somewhat sharp eIastic resistance encountered in penetrating the dura is recognizabIe, and serves to orient the point of the needIe; if it does not, the needIe impinges against the centrum of the vertebra and shouId then be sIightIy withdrawn. Sharp
Anesthesia
DECEMBER,
1928
pain referred to either Ieg, or a flow of bIood from the needIe indicates that the point has been directed too much IateraIIy; it shouId be withdrawn and reinserted, sometimes best at the next higher IeveI. The end resuIts have been uniformIy satisfactory except as above noted. The anesthesia ensues very promptIy upon the injection, and passes off just as promptly. There is no post-anesthetic depression, distress, or disturbance of menta1 equilibrium. The method as appIied to obstetrics is again offered, not in any sense as original, but as one deserving, in the interest of much wider use than it has patients, hitherto enjoyed.